A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Expresses that they cannot get enough air to breathe.

Respiratory rate of 7 breaths/minute.

Bilateral wheezing on auscultation.

Pulse oximeter reading of 89% on room air.

Answer and Explanation

The Correct Answer is B

A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.

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Correct Answer is A

Explanation

A) Determine what time the dose is taken: The timing of medication administration, especially for stimulant medications like dextroamphetamine-amphetamine, can significantly impact sleep quality. If the client is taking the medication too late in the day, its stimulant effects may interfere with their ability to fall asleep at night. Therefore, assessing the timing of medication administration is crucial to determine if it correlates with the reported difficulty sleeping.
B) Ask about the client's bedtime routine: While bedtime routine can influence sleep quality, it may not directly address the issue of difficulty sleeping related to medication use. However, understanding the client's overall sleep habits and bedtime routine can provide valuable information for developing sleep hygiene recommendations.
C) Inquire about perceived anxiety: Anxiety can contribute to sleep disturbances, but in this context, the primary concern is the potential impact of dextroamphetamine-amphetamine on sleep. While anxiety assessment is important in comprehensive care, it may not directly address the client's reported difficulty sleeping specifically related to medication use.
D) Determine daily caffeine intake: Caffeine intake can affect sleep quality, but it may not be as directly relevant to the reported difficulty sleeping in the context of medication use. However, it's still valuable information to assess as part of the overall evaluation of sleep habits and factors contributing to sleep disturbances.

A. Begin therapy 1 week before the next normal menstrual cycle. B. Use condoms and a backup method of birth control to prevent pregnancy. C. Ensure a negative pregnancy test result 2 weeks before therapy. D. Call the healthcare provider immediately if there is a chance of conception.

Correct Answer is A

Explanation

A) Begin therapy 1 week before the next normal menstrual cycle:
Misoprostol is often prescribed to prevent gastric ulcers induced by nonsteroidal anti-inflammatory drugs (NSAIDs) and is typically taken regularly with meals and at bedtime. The timing of therapy initiation is not necessarily linked to the menstrual cycle. Therefore, instructing the client to begin therapy specifically 1 week before the next normal menstrual cycle is incorrect and indicates a need for further teaching.

B) Use condoms and a backup method of birth control to prevent pregnancy:
Misoprostol is contraindicated during pregnancy due to its potential to induce uterine contractions and cause miscarriage or fetal abnormalities. Therefore, advising the client to use condoms and a backup method of birth control to prevent pregnancy while taking misoprostol is appropriate and aligns with safety precautions.

C) Ensure a negative pregnancy test result 2 weeks before therapy:
Confirming a negative pregnancy test result before initiating misoprostol therapy is essential because the medication can cause harm to a developing fetus. This instruction is correct and reinforces the importance of avoiding pregnancy while taking misoprostol.

D) Call the healthcare provider immediately if there is a chance of conception:
Given the teratogenic effects of misoprostol, advising the client to contact the healthcare provider immediately if there is a chance of conception is crucial. This instruction emphasizes the importance of avoiding pregnancy while taking the medication and seeking medical guidance promptly if pregnancy is suspected.

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A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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